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SAN JOAQIA✓COUNTY ENVIRONMENTAL HEALTh.APARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Ser✓/te 574a4-lo✓7 AAX1+'131 S42-cc 'A ,9 3--i <br /> OWNER/OPERATOR 1 r CHECK If BILLING ADDRESS❑ <br /> FACiUTY NAME S 7 C^D w l//o l esa /e/ <br /> SITE ADDRESS 3Z So 6t^4 rn4h e— RbYzd Trac 95370 <br /> Street Number Direction C Zi Cetle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ear. APN# LAND USE APPLICATION# <br /> PHONE#2 Eu. BOS DISTRICT LOCATION CODE <br /> t I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 44 h lee n !-fie nS Ak <br /> CHECK K BILLING ADDRES <br /> BUSINESS NAMEPHONE# Ear' <br /> Ceh-/ra/ Pe4roteav;1 q24-) '/1P2-"0 <br /> HOME or MAILING PRES FA%# <br /> CITY Plea-ga t74oPi STATE e'1. LP el'v <br /> Lq <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent°of same, <br /> acknowledge that all Site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, TATE and FEDERAL laws. // � � <br /> APPLICANT'S SIGNATURE: *.C.u"'p--W"t<2a.(�[,J� DATE: <br /> ,/ <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTRERAUTHORIZED AGENT L7 <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. IN�1' <br /> -AYM <br /> TYPE OF SERVICE REQUESTED: �/)'T �/i �'Y r <br /> COMMENTS: <br /> SEP 2 9 Zoos <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMEFIT <br /> ACCEPTED BY: EMPLOYEE#: DATE: _ S� <br /> ASSIGNED TO: EMPLOYEE#: b—ls- DATE: Gj -2-g- <br /> Date Service Completed (if already completed): SERVICE CODES: 9 PIE: 7 /J9 <br /> Fee Amount: 5 Amount Paid — Payment Date �' <br /> Payment Type Invoice# Check# 0291 Received By: <br /> EHD 49-02-025 SR FORM(Golden Rotl) <br /> REVISED 11/17/2003 <br />